Wednesday, January 30, 2013

No room at the Inn part II

BHRUT declare a major internal incident in A&E and Bart’s Health are forced to buy community beds to support Whipps

A&E at Queen’s and King George has reached crisis point.  From the end of October last year there has been a steady fall off of performance which has seen only 60-65% of patients seen within four hours on some days against the target of 95%.  On average in December the figure was 81% with King George performing much better than Queen’s. The NELC Board papers of 30th January describe Queen’s as having “...sustained and significant underperformance.”

The BHRUT Board meeting on January 9th heard that waits of over eleven hours have been recorded at Queen’s. This is a major blow for the Trust because of the enormous amount of time and money that has been invested in the ‘RESET’ programme over the last six months run by the consultancy firm McKinsey which was supposed to resolve the A&E performance issues.

Looking at the performance graph in the NELC papers one of the most worrying features is the marked downward trend from the middle of October last year until the end of December when the graph finishes.  There is no sign of the trend “bottoming out” and it represents almost a full quarter of rapid deterioration.

At a glance

·        BHRUT have the worst A&E performance figures in London

·        The major incident in A&E has not been fully and openly reported

·        Bed closures are putting unsupportable pressure on patient flows

·        Problems are now being experienced by Whipps and extra community beds are being purchased

·        The commissioners have sent a ‘contract query note’ which will do little to help and will put more pressure on the Trust

·        Closing the A&E at King George is not feasible in the short term and the NHS should look for a longer term solution

A major internal incident

Equally disturbing is the news from the NELC Board papers[: “The level of pressure has continued into early January leading to the Trust declaring an (sic) major internal incident, increasing staffing win the ED (Emergency department) and opening a further 16 beds as contingency capacity and there is no further contingency capacity available.“

What is surprising is that there was no mention of the “major internal incident” in the BHRUT papers.  In fact there is no narrative report at all just a tabular action plan.  There was some discussion of the problems at their public Board meeting with a number of members describing the situation as unacceptable.

Major incidents are usually large scale civil emergencies such as fires or floods which generate many casualties.  It is very unusual for a hospital to declare one for internal reasons and certainly not because of pressure in A&E.  There is a clear requirement in Section 7 of the guidance for the Trust to maintain communication with the local community, the media and VIPs.

A briefing note for Scrutiny members sent out by BHRUT on 21st January does give some basic facts and acknowledges that the long waits are a serious concern but makes no mention of the ”major internal incident” again.

The response from the commissioners has been to increase the pressure on the Trust by introducing a “contract query note” and an action plan to improve the situation. More money is being made available for a fourth stage of ‘RESET’, again with McKinsey.

The origins of the problems

To many of us this situation, desperately worrying as it is, comes as no surprise.  The underlying problems of Queen’s and King George are:

Firstly, that the catchment area of the hospitals is so much larger than others in NE London. The two probably serve upwards of 800,000 to 900,000 people while Newham, Whipps and the other hospitals cover more like 250,000 to 350,000.

Secondly, trying to reduce beds puts unsupportable pressure on patient flows in Queen’s and King George and leads to the diversion of emergency ambulance cases to other hospitals.

Consequently problems at Whipps are starting to emerge as well, with Barts Health having to spot purchase continuing care and rehab beds to relieve the pressure on A&E. The Hospital has been closed to emergency ambulance cases on an unknown number of occasions in December and January. This is against a background of as yet undeclared plans to close community beds by NELC which form an important outlet for discharges. The ominous news that BHRUT have run out of contingency beds underlines the seriousness of the situation.

There may be cross boundary flows to other hospitals and some ‘smoothing’ by the Ambulance service redirecting emergencies when departments are full but this cannot compensate for these two factors.  The bad news is that this can only get worse as the population rises every year and the national trend for increased attendances at A&E departments continues.

Elected members, campaigners and others have been warning about this since the start of the Health4NEL process.

The commissioners’ response

Putting pressure on the BHRUT could be counterproductive and morale must be affected by the situation.  When people are doing their best in difficult circumstances a ‘contact query note’ doesn’t offer much and given that ‘RESET’ and McKinsey have not really solved the problems spending more on this approach may again be counterproductive.

Are BHRUT conforming to the standards in public life?

It is also very worrying in governance terms that a full written report on the situation was not made at the January 9th BHRUT Board meeting. There is also no statement on the website or the newsletter for members about the major internal incident.  NELC are to be congratulated for putting the information in the public domain but there is clearly a responsibility on BHRUT to inform the public and to be open as part of the “Standards in Public Life” agenda.

How to move forward

There needs to be a recognition on the part of the NHS that closing the A&E at King George is not achievable in the short or medium term and to start looking at longer term trends to see how viability for services in NE London could be achieved

We know we have a lot of debt/investment much of it tied up in expensive PFIs, the population is one of the fastest growing in the UK and we have significant workforce issues particularly around Maternity.  All of this needs to be balanced against efficiency gains and the Darzi principles of centralisation and specialisation.

I support these strongly, but there is a growing risk that by attempting to do too much too quickly progress may in fact be slowed down.  What you can do safely in five or ten years you cannot do in two.

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